Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Adult Foster Care


Adult foster care is typically provided in a private home, offering 24-hour support to one or more individuals. Most commonly the support is provided by the owners of the home, although foster care providers may engage other individuals to provide care. In some states, corporate entities oversee and manage foster homes. States may contract with each primary caregiver for the provision of adult foster care services, and/or contract with agencies that, in turn, contract with and supervise individual caregivers. In addition to room and board, foster care providers typically furnish assistance with daily living activities and help in accessing community activities.

Definition of Adult Foster Care in HCBS Waiver Application

“Personal care and supportive services (e.g., homemaker, chore, attendant care, companion, medication oversight [to the extent permitted under state law]) provided in a licensed (where applicable) private home by a principal care provider who lives in the home. Adult foster care is furnished to adults who receive these services in conjunction with residing in the home. Separate payment is not made for homemaker or chore services furnished to a participant receiving adult foster care services, since these services are integral to and inherent in the provision of adult foster care services.”10

States may use this definition, or modify or supplement it to reflect the scope of adult foster care to be furnished through a waiver program.

Adult foster care homes serve individuals with a wide range of disabilities, including those with physical and/or cognitive impairments, serious mental illness, and developmental disabilities. Arizona, Maine, Oregon, Washington, and Wisconsin, among other states, offer adult foster care as a means to keep older adults connected to their home communities when they can no longer live alone. Oregon has made efforts to recruit and train foster care providers for older adults specifically to increase the viability of this option as an alternative to nursing homes.11

Most foster homes serve a relatively small number of individuals. As an example, in 2007, of the 23,848 family foster homes serving individuals with developmental disabilities, only 652 served four or more individuals, with the maximum number nationally being six individuals.12 In an HCBS waiver program, adult foster care is considered a residential habilitation service for individuals with developmental disabilities only when habilitation is included in the defined scope of the adult foster care service; it is not considered a residential habilitation service when habilitation services are furnished in the adult foster care setting by a different provider and billed separately.

Adult foster care settings usually are licensed or certified; 17 states regulate these settings for older adults under assisted living regulations.13 States have flexibility in setting provider standards but most require specialized training to support specific populations, such as adults with developmental disabilities and older adults with dementia.

Moving from Adult Foster Care to Shared Living Arrangements

To better support individuals with developmental disabilities, new, more personalized approaches to adult foster care are being used, such as Shared Living. The purpose of Shared Living is to create a more equal arrangement than is found in traditional foster care--one based on mutual choice. In Shared Living, the individual with a disability and the provider choose to live together. Although the provider furnishes support and supervision, the expectation is that the relationship is more equal and more personal than is typically the case in foster care.

A Shared Living arrangement is usually in the Shared Living Provider’s home or apartment, but could also be in the home or apartment of the individual with a disability, in which case it would be considered a home-based supports approach. Many different arrangements can be developed based on individuals’ unique needs and situation.

A human services agency in Pennsylvania serving individuals with developmental disabilities offers a foster care approach called Lifesharing Thru Family Living. This approach provides an option for people with developmental disabilities to be active, participating members in a family and the community in which the family lives. This approach emphasizes the importance of matching individuals and families to enable harmony in values, interests, and mutual commitments. Family Living Specialists work closely with the family and the individual, and serve as the primary support to ensure a successful match. For more information, see http://www.skillsofcentralpa.org/public/services/lifesharing.php.

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